69955
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
28.68
Facility
$1707.45
Non-Facility
$1707.45
Key Coverage Criteria
- the procedure is reasonably expected to improve the functional impairment;and
- an audiogram documents a loss of at least 15 decibels in the affected ear(s).
- Facial plastic surgery is consideredmedically necessarywhen required tocorrect a significant functional impairmentandthe procedure can be reasonably expected to improve the functional impairment. Examples include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of speech, nutrition, control of secretions, protection of the airway, or corneal protection.
- Facial plastic surgery is consideredreconstructivewhen intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.Note:The initial restoration may be completed in stages.
- Otoplasty is consideredmedically necessarywhen performed to surgically correct a physical structure or absence of a physical structure that is causing hearing loss, or intended to facilitate the use of a hearing aid or device whenbothof the following criteria are met:
- Otoplasty is consideredreconstructivewhen intended to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.
1 Active Policy
ANTHEM-MP-A050276 — ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
Related Codes
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